=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073565115
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIAGNOSTIC RADIOLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2006
-----------------------------------------------------
Last Update Date | 09/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 902 S BRYANT AVE
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73034-5742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-348-1900
-----------------------------------------------------
Fax | 405-348-0423
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2080
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73083-2080
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-348-1900
-----------------------------------------------------
Fax | 405-348-0423
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING OFFICE MANAGER
-----------------------------------------------------
Name | BECKY M JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-348-1900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------